As someone with "purely obsessional" OCD, most of my therapeutic exposures
are imaginal exposures.
Imaginal exposures
are deliberately conjured thoughts that touch on one or more obsessive
themes and evoke anxiety. Two common types of imaginal exposures are
scripts, which are stories—often idiosyncratic—that express one's
worst fears about what has happened or what will happen, and
mental images, which are mental representations of disturbing or
distressing pictures, sounds, sensations, and so on. The task is to rehearse
these thoughts or scripts over and over (sans compulsions) until
habituation is achieved. In other words:
Think it until it's boring.
In lieu of real world exposures, imaginal exposures are often assigned to
those who suffer from harm OCD, POCD, scrupulosity, and "taboo thoughts" in
lieu of real world exposures, which often aren't feasible. It's not just
that "go punch someone in the face" isn't a particularly ethical exposure;
it's that
it wouldn't help regardless. People with "Pure O" share a common set of cognitive distortions that
need to be challenged differently. The distortions include:
1. My thoughts say a lot about my character.
2. Failing to suppress "bad thoughts" is equivalent to wanting these
thoughts.
3. Thinking "bad thoughts" opens the floodgates to doing bad things.
4. If I think of something catastrophic, it's likely to occur in the future
or to have occurred in the past.
Each of these distortions manifests a pathological response to the
phenomenon of having thoughts with distressing content. The
sufferer's orientation to the reality represented by thoughts is not the
issue. People with "Pure O" are indeed averse to murder, assault, and the
like, and that's not a problem to be solved! The problem is that obsessive
people are pathologically fearful of thoughts that threaten their
self-conception or portend imminent doom. So even if,
per impossibile, it was ethical to assault someone for the sake of an
exposure, it wouldn't be effective, because that's not where the actual fear
lies. The feared stimulus is the thought; habituation consists in reducing
fear response to the cognitive phenomenon. Hence, imaginal exposures.
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| Photo by Annie Spratt on Unsplash |
Isn't it bad to imagine bad things?
As a philosopher, I have an annoying, arrogant habit of questioning the
things that promise to get me better. Naturally, my questioning becomes even
more "astute and incisive" when I'm looking for an excuse to get out of a
distressing exposure. As I'm preparing to think yet another terrible,
no-good thing for 30 agonizing seconds, I'm tempted to ask:
What makes me different from a bona fide creep? Is there not
something rational about these so-called "cognitive distortions". Someone
who constantly fantasizes about murder probably has some propensity to
murder, and their murderous thoughts probably say something about their
character. If I start deliberately thinking the same things, what makes me
different?
The standard psych response is:
Obsessions are
ego-dystonic, whereas bona fide creepy thoughts are ego-systonic. Creeps want to think creepily; they enjoy it. OCD sufferers do not.
But for someone with OCD, this just begs the question. Obsessive people fear
that their thoughts reflect their true selves: their characters, their
wishes, their intentions. That's precisely why they are frightened by their
thoughts. "But you wouldn't be frightened if you truly wanted these
thoughts!" An obsessive mind, creative as it is, will not be mollified so
easily. Can't a creep be reluctantly creepy? What if I'm just a creep with a
conscience?
And yet, somehow, ERP can break through this exhausting barrage of obsessive
retorts—if you are willing to "go there". But if you struggle to see what
separates you from a creep, how do you consent to go there? How is this not
intolerably dangerous? Sure, it's well-established that people with OCD
don't do the things they're afraid of, but I could always be the exception.
And isn't thinking the thought terrible enough?
From Bad Thoughts to Good Performances
I used to treat imaginal exposures as a special kind of imaginary practice,
as something that isn't comparable to any other kind of imagining. It felt
like a shameful (albeit necessary) practice which only therapists and my
wife could truly understand. I now think of imaginal exposures in less
spooky terms.
Imaginal exposures are method acting exercises; they are ways of
figuratively becoming one with a character. When you practice ERP, you are simply acting, albeit to a house of one. And
when you write an ERP script, you are playwriting in a quite literal sense.
We can think of method acting as
imaginative immersion
in the thoughts, values, and motivations of a character. It involves
virtually "putting on" someone else's mindset, just as one might put on a VR
headset to see the world through another person's perspective. The "method"
part amounts to fully immersing yourself in the character,
allowing the character's thoughts, feelings, and values to push your own
thoughts, feelings, and values outside of conscious attention. Crucially,
your own thoughts remain in conscious awareness; you do not literally
forget who you are or where you are. But while you are immersed, you are not
attending to these facts. This is the sense in which a method actor
"becomes" their character.
When engaging in imaginal exposures, particularly ones involving
ego-dystonic scripts, you are playing the role of someone whom you fear
being or becoming. To properly play the role, you have to fully immerse
yourself in the character, attending only to their thoughts and beliefs
without attending to your own thoughts and beliefs (which does not amount to
losing awareness). Hence therapists' demands that patients not engage in
compulsive practices such as thought suppression and reassurance-seeking
during exposure and response prevention; compulsions rip you out of the mind
of the character and send you back to your real mind. The purpose of this
performance is to demystify unwanted thoughts, feelings, and desires,
showing that they do not actually contaminate or distort your true self.
This model helps explain why imaginal exposures feel scary but aren't
actually dangerous. The experience of immersing oneself in an abhorrent
character can be discomfiting to say the least—at least until you habituate.
But method actors aren't dangers to the public. In general, it would be
silly to discourage someone from playing an abhorrent character for fear
that they will become abhorrent—that their true self will be eroded by one
fateful performance. If normal people can immerse themselves in creepy
characters without becoming creepy themselves, it stands to reason that
those who are antecedently terrified of becoming creepy (read: people
with OCD) are similarly protected from character contagion.
As it is for method acting, so it is for ERP. Imagining doing terrible
things for the sake of an exposure does not erode your character. That's not
because thoughts have no power; it's because exposures, as acting exercises,
don't have that kind of power. Exposure thoughts are designed to
induce habituation, and they do this effectively.
Being Creepy vs Acting Creepy
Let's return to the question that motivated this excursion:
What makes an ERP-er different from a creep? We've established that
the content of an exposure thought is no different than the content of a
creepy thought. Even the collective contents of attention are no different;
fanaticizers and ERP-ers are attending to all the same thoughts, beliefs,
and feelings.
What separates ERP-ers from creepers are the contents of awareness. Just as
a method actor is aware that they are acting while performing—as evidenced
by their "cheating out", their adherence to the script, and their ability to
snap out of character when the performance is over—so ERP-ers are aware that
the contents of their exposures do not represent or express their stable
characters, despite recalcitrant fears to the contrary. As long as they have
sufficient insight, OCD sufferers are aware that they are not murder
aficionados. Imagining otherwise, even with full commitment, doesn't deprive
them of this awareness.
This account helps explain why creepy thoughts are ego-systonic and exposure
thoughts are ego-dystonic. In the mind of a creep, attention and awareness
are in lock-step. In the mind of an OCD sufferer, attention and awareness
are in tension. And this tension explains why exposures are
anxiety-inducing; our minds abhor dissonance, especially when that
dissonance is construed as a threat to one's self-concept. Finally, this
account explains why exposures are unlikely to "infect" one's character.
Actors can temporarily inhabit roles, and OCD sufferers can temporarily
inhabit creeps. As it is difficult for an actor to truly forget that they
are acting, so it is difficult for an OCD sufferer to truly forget they are
engaging in ERP. In other words, imaginative immersion during an exposure is
unlikely to induce psychosis.
What this model fails to explain is how ERP achieves its objective: to turn
terrifying thoughts into merely annoying thoughts by the power of
habituation. I confess I don't have a great answer here, but maybe it has
something to do with demystifying "the method", or maybe it comes from
experiencing your OCD script for what it is. In the course of performance,
what starts as a gripping horror picture turns into an "edgy" student film.
The first is intolerable, the second merely insufferable. When you rehearse
your script enough times, you begin to realize that your OCD has a
sophomoric pen. The material starts to feel irredeemably silly, and
credulity gives way to eye-rolls.
Imaginal exposures give the illusion of danger. Indeed, they wouldn't be
effective otherwise. But it is truly an illusion. That's because each
imaginal exposure is just a role that the OCD sufferer temporarily assumes
for a specific therapeutic purpose. To be sure, immersing oneself in an
abhorrent character is frightening. But not all fears represent real
dangers. And that may be the ultimate lesson of ERP.
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